Principles and practice of withdrawing life-sustaining treatments
Section snippets
Principles of withdrawing mechanical ventilation
In this era of evidence-based medicine, there is a lack of data to direct clinicians in the optimal management of the dying critically ill patient. Despite the lack of data on optimal management of some aspects of withdrawing life-sustaining treatment, a general consensus exists on the ethical and clinical principles that should guide this care. These six principles are listed in Box 1 [11], [12], [13].
Understanding that the goal of withdrawing life-sustaining treatments is to remove unwanted
The decision to withdraw life-sustaining treatments
Ethical and legal guidelines for decisions to withdraw life-sustaining treatments are well established, and have been presented elsewhere [12], [15]. Competent, informed patients may refuse any life-sustaining treatment. For incompetent patients, appropriate surrogates may refuse life-sustaining treatments based on written advance directives or, in almost all states, the patient's previously stated wishes, values, or best interests . In some circumstances it is ethically appropriate for
Informed consent
Like other medical procedures, withdrawal of life support should be accompanied by informed consent, or at least assent, and documentation of this process in the medical record. Informed consent for the procedure of withdrawing life-sustaining treatment does not refer to the process of signing a consent form. It refers to a process of communication between caregivers and families that focuses on the burdens and benefits of life-sustaining treatment and the options for alternate care. Competent
Appropriate setting and monitoring
Transforming the ICU into a suitable place to fulfill the new goals of terminal care is not a simple task. The ICU and its staff are poised to respond to minor physiologic changes. Comfort, dignity, family access, and quiet may not always receive the highest priority. Particularly when family members and friends will be in attendance, the goal should be to have the patient clean and comfortable in a quiet room devoid of technology and alarms that affords the patient and family privacy. The
Sedation and analgesia
Before performing uncomfortable procedures, clinicians provide patients with adequate medication to prevent anxiety and suffering. Critically ill, hemodynamically unstable patients may not receive optimal sedation when drug-related hypotension or respiratory suppression compromises the goals of maintaining life or liberation from mechanical ventilation. However, when the goal of care is changed to assuring patient comfort, any dosage of medication that is required to meet this goal is
A plan for withdrawal
Before physicians perform procedures like intubation or central venous catheterization, they have a clear plan of action as well as contingency plans for complications. A similar plan should be developed for withdrawing mechanical ventilation. Physicians need to consider which life support measures will be discontinued, in what order, and by whom.
Once a decision has been made to orient the patient's care to comfort, the only criterion to use to judge whether a treatment should be initiated,
Pastoral, nursing, and emotional support
Before interventions are withdrawn, the family should be asked if a priest, pastor, rabbi, or other religious advisor should be called. Caring for patients after life-sustaining technology is withdrawn can require the same level of vigilance and time that aggressive life support requires. Nursing attention should be directed to hygiene, skin care, interacting with family members, and maintaining a quiet environment within the busy ICU. Treatments that may alleviate or prevent uncomfortable
Documentation
Progress notes in the medical record should document the meetings leading up to the decision to withdraw support, the specific plans for withdrawal, and the pharmacologic plan for sedation. This is particularly important because nurses or covering physicians who implement the plan may not have been involved in the original decision or discussions. Although meetings with surrogates need not address specific decisions regarding every piece of life-support technology, communication with other
Evaluation
Quality improvement procedures are important for evaluating the withdrawal of life support and the process of dying, just as they are for other hospital procedures. Members of the hospital critical care committee should review the circumstances of these deaths to evaluate the care. Those involved in the withdrawal of care, including family members, should have the opportunity to evaluate the quality of dying and suggest improvements for the future. These suggestions should be incorporated into
Noninvasive mechanical ventilation
The increasing availability of noninvasive mechanical ventilation provides another option for managing ventilatory support. At least some patients with respiratory failure who were expected to die without intubation and mechanical ventilation can be managed with noninvasive mechanical ventilation [33]. To determine whether this is appropriate, it is essential that clinicians clarify what a patient is refusing when they request not to be “intubated.” Clinicians should view noninvasive mechanical
Summary
The clinician's responsibility to the patient does not end with a decision to limit medical treatment, but continues through the dying process. Every effort should be made to ensure that withdrawing life support occurs with the same quality and attention to detail as is routinely provided when life support is initiated. Approaching the withdrawal of life support as a medical procedure provides clinicians with a recognizable framework for their actions. Key steps in this process are identifying
References (38)
- et al.
Biases in how physicians choose to withdraw life support
Lancet
(1993) Terminal weaning
Chest
(1995)- et al.
Terminal events in the intensive care unit: review of 258 fatal cases in one year
Crit Care Med
(1989) - et al.
Increasing incidence of withholding and withdrawal of life support from the critically ill
Am J Respir Crit Care Med
(1997) Terminal weaning”; discontinuance of life-support therapy in the terminally ill patient
Crit Care Med
(1983)- et al.
Process of forgoing life-sustaining treatment in a university hospital: an empirical study
Crit Care Med
(1992) - et al.
Principles of critical care
(1992) - et al.
Withdrawing intensive life-sustaining treatment—recommendations for compassionate clinical management
N Engl J Med
(1997) Forgoing life-sustaining therapy: how to care for the patient who is near death
(1998)
The role of critical care nurses in euthanasia and assisted suicide
N Engl J Med
A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators
JAMA
Withholding and withdrawing life-sustaining therapy. This Official Statement of the American Thoracic Society was adopted by the ATS Board of Directors, March 1991
Am Rev Respir Dis
Resolving ethical dilemmas: a guide for clinicians
Clinical ethics: a practical approach to ethical decisions in clinical medicine
A multi-institutional study of care given to patients dying in hospitals. Ethical and practice implications
Arch Intern Med
Principles of biomedical ethics
Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians' practices and patients' wishes
Am J Respir Crit Care Med
Decisions about resuscitation: inequities among patients with different diseases but similar prognoses
Ann Intern Med
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